The AHA Central Office on ICD-10-CM/PCS has continued to receive requests for assistance in applying ICD-10-CM’s 7th characters. The following examples are intended to help clarify the use of the 7th characters when coding encounters for physical therapy and home health care:
Please clarify which guidelines in the ICD-10-CM Official Guidelines for Coding and Reporting apply to physical therapists reporting diagnoses for outpatient physical therapy treatments. For example, does the guideline under Section I.B.5 conditions that are an integral part of a disease process apply?
Yes. The guidelines in Section I, Conventions, General Coding Guidelines and Chapter Specific Guidelines, apply to all providers, including physical therapists. If the symptom is integral to the diagnosis it would not be separately coded. Guidelines in Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services, also apply to providers reporting diagnoses in outpatient settings.
A patient was diagnosed with a right traumatic anterior cruciate ligament (ACL) tear and presents for outpatient physical therapy treatment. The physician’s prescription documents, right ACL tear, right knee pain and difficulty walking. What diagnosis codes should be reported?
Assign code S83.511D, Sprain of anterior cruciate ligament of right knee, subsequent encounter, as the first-listed diagnosis. The underlying condition (sprain) is coded. This is not active treatment of the ACL tear and therefore 7th character “D” subsequent encounter is assigned. Do not assign codes for difficulty walking or knee pain since these signs and symptoms are routinely associated with ACL tear. According to Section I.B.5 of the guidelines, “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.”
A patient was referred to outpatient physical therapy ten days post discharge from the acute care hospital burn center. He had suffered third degree burns to both the right and left lower leg and thigh as a result of ignition of gas, which occurred while refueling his car. Physical therapy was providing wound care for the burn. What is the appropriate 7th character for the encounter for physical therapy?
Active wound treatment is active treatment. The primary reason for physical therapy is the burn injury, and the appropriate 7th character is “A” initial encounter. Assign codes T24.391A, Burn of third degree of multiple sites of right lower limb, except ankle and foot, initial encounter, and T24.392A, Burn of third degree of multiple sites of left lower limb, except ankle and foot, initial encounter. Code X04.XXA, Ignition of highly flammable material, should also be assigned to identify the external cause of the injury.
A patient sustained a Colles’ fracture of her left upper extremity after slipping and falling on an icy sidewalk four months ago. At that time, she was admitted and the fracture treated by open reduction and internal fixation. After discharge, a routine follow-up x-ray demonstrated a healing fracture. Because the patient was complaining of weakness and achiness in her hand and wrist, the orthopedist referred her for outpatient physical therapy. The therapist performed functional training, static stretches and strengthening exercises. What is the appropriate 7th character for the encounter for physical therapy?
Assign code S52.532D, Colles’ fracture of left radius, subsequent encounter, for closed fracture with routine healing, as the reason for the encounter. Code also W00.0XXD, Fall on same level due to ice and snow, subsequent encounter, to describe the external cause of the injury. The patient is receiving physical therapy during the healing phase of the fracture.
The patient is referred to outpatient physical therapy for rehabilitation and functional training following an admission for treatment of skin contractures resulting from a third degree burn of the left hand in a house fire two years ago. How should the visit to the physical therapist be coded?
Assign code L90.5, Scar conditions and fibrosis of skin, as the first-listed code. Assign codes T23.302S, Burn of third degree of left hand, unspecified site, Sequela, and X00.0XXS, Exposure to flames in uncontrolled fire in building or structure, sequela, to describe the specific injury and external cause. Skin contractures are a sequela of the previous burn injury.
The patient presents to outpatient physical therapy for follow-up of healing third degree burns of the chest wall that occurred due to a house fire four-months ago. The physical therapist performed exercises to help keep the burned area flexible in the healing process. What is the appropriate seventh character assignment for the burn injury?
Assign code T21.31XD, Burn of third degree of chest wall, subsequent encounter, as the first-listed diagnosis. Code X00.0XXD, Exposure to flames in uncontrolled fire in building or structure, subsequent encounter, should be assigned to describe the external cause of the burn. According to coding guidelines, 7th character “D” subsequent encounter is used for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.
An elderly patient with end-stage Alzheimer’s disease, dementia and functional quadriplegia, who is completely immobile due to bilateral joint contractures of the hip and knees, receives home health care and daily physical therapy consisting of passive range-of-motion exercises. What codes should the physical therapist report?
Assign any of the applicable contracture codes (i.e., M24.551, Contracture, right hip, M24.552, Contracture, left hip, M24.561, Contracture, right knee, M24.562, Contracture, left knee), as the first-listed diagnosis. Codes R53.2, Functional quadriplegia, G30.9, Alzheimer’s disease, unspecified, and F02.80, Dementia in other diseases classified elsewhere without behavioral disturbance, should be assigned as additional diagnoses.
A patient with a known diagnosis of Parkinson’s disease with frequent falls and lack of coordination is referred by the physician for physical therapy for fall prevention. What diagnosis codes should be reported for the physical therapy visit?
A patient with low back pain and sciatica with left lower extremity pain radiating to the knee and difficulty walking was seen by an orthopedist and referred to physical therapy (PT). The primary reason that PT is involved is to resolve the pain and improve mobility. What diagnosis codes should be reported for the physical therapy visit?